Insulin Options

Question 1

What chemical was added to insulin in 1950 that is still used today to increase the half life of insulin?

Answer 1

Protamine

Question 2

Purified pork insulin 7 then recombinant human insulin virtually eliminated what diabetic complication?

Answer 2

Insulin allergy & immune-mediated lipoatrophy

Question 3

What are older insulins more commonly associated with?

Answer 3

hypoglycemia

Question 4

Weight gain while on insulin is due to what 4 things?

Answer 4

• anabolic effects of insulin
• increased appetite
• defensive eating from hypoglycemia
• Caloric retention r/t decreased glycosuria

Question 5

Insulin is a very common offender in causing ER visits due to hypoglycemia. What is a common reason for this?

Answer 5

Inability to draw up an accurate dose

Question 6

Prandial insulins (Bolus)

Answer 6

Fast acting: Regular

Faster acting: Lispro, aspart, glulisine, human (inhaled)

Question 7

Basal insulins

Answer 7

Intermediate acting: NPH

Long acting: Glargine, determir, degludec

Question 8

Biphasic combination that is commonly used

Answer 8

70% NPH/30% regular

Question 9

What is a pearl about insulin metabolism

Answer 9

Insulin is broken down in the kidney

If CKD, decrease dose to compensate

Question 10

Prandial Insulin MOA

Answer 10

-Act on specific membrane-bound receptors on target tissues to regulate metabolism of carbohydrates, protein, and fats

***Also increases cellular permeability to several ions (K, Mg, phos)

Question 11

Regular insulin pearls

Answer 11

• Cheap
• Good for DM gastroparesis (later onset when gastric emptying occurs)
• less physiologic and causes more hypoglycemia

Take 30 min before meal

Question 12

“Faster” insulin pearls

Answer 12

• superior to regular insulin in reducing postprandial hyperglycemia
• More rapid pharmacodynamics make post-absorptive hypoglycemia less common than in regular insulin
• $$$$ (expensive)

Take right before first bite

Question 13

Faster insulin and exercise

Answer 13

Patients who exercise 1–3 hrs after a meal require dose reduction

Question 14

Inhaled insulin (human)

Answer 14

• expensive
• Not used much
• Pax daddy fatty bong rips

Question 15

Prandial insulin interactions/ADRs

Answer 15

• All agents have longer half life with CKD
• Hypoglycemia
• weight gain

Question 16

NPH pearls

Answer 16

• cheap and familiarity
• Less physiologic, causes more hypoglycemia (nocturnal)
• Erratic pharmacokinetics

Question 17

Glargine: onset, peak, duration, meal timing

Answer 17

• Onset: 1 hr
• Peak: none
• Duration: 24 hrs
• Meal timing: take at same time of the day

Question 18

Detemir: onset, peak, duration, meal timing

Answer 18

• Onset: 1-2 hrs (dose dependent)
• Peak: flat
• Duration: dose dependent, low = 12hrs, high =20-24hrs
• Meal timing: qday = PM meal or hs, BID 12 hrs pAM dose

Question 19

Degludec: onset, peak, duration, meal timing

Answer 19

• Onset: 30-90min
• Peak: none
• Duration: 42 hrs
• Meal timing: no requirements

Question 20

Advantages of Basal Insulin Analogues

Answer 20

• Long duration of actions (qday)
• No peak
• Less nocturnal hypoglycemia

Question 21

Disadvantages of Basal Insulin Analogues

Answer 21

• Generally cannot be mixed with other insulins*
• Slower onset of action
• If OD, prolonged risk of hypoglycemia

Question 22

CI with Basal Insulin Analogues

Answer 22

All agents have a longer half life with CKD*

Question 23

ADRs of Basal Insulin Analogues

Answer 23

Hypoglycemia, weight gain

Question 24

Biphasic Insulins (include onset, peak, duration, admin, timing, color)

Answer 24

70% NPH, 30% regular

• Onset: 30 to 60min
• Peak: 2-12 hrs
• Duration: effective 10-15 hrs
• Admin: SC bid
• Meal timing: 30 min before meal
• Color cloudy

Question 25

Clinical use of biphasic insulins

Answer 25

• For patient unwilling to do >2 injections per day*

- Minimal use overall (duration of action longer in CKD, less flexibility, $$$)

Question 26

Where does insulin rank in comparison to metformin/other oral drugs? Is it first line, second line, etc?

Answer 26

Consider insulin second line after metformin IF A1c is >/= 9%, especially if asymptomatic

Question 27

Rundown of initiating insulin therapy - where do you start, and what are the next three options?

Answer 27

-Start with longer-acting, “basal” insulin once daily
THEN
-Option 1: add GLP-1 agonist, can help limit weight gain due to insulin
-Option 2: add “prandial” insulin at largest meal
-Option 3: switch to premixed insulin BID (less cost)

Question 28

Pearl about sliding scale insulin, w

Answer 28

This chases glucose, doesn’t control it

Question 29

Sliding scale insulin options

Answer 29

• Option 1: basal insulin
• Option 2: basal plus short/rapid acting
• Option 3: basal bolus (basal qday or BID plus short-acting before each meal)

Question 30

Options for pregnancy

Answer 30

• Diet/nutritional counseling and exercise
• Oral agents (metformin = B)
• Insulin = gold standard/drug of choice if not controlled with diet/exercise (NPH and regular have the most safety data)